Pubovaginal Sling Procedure (PVS) & Male Urethral
Sling

Definition

Vaginal = means the surgery is being
done (in total or in part) through the vagina

Sling = a material placed around
a structure in order to provide it support

The pubovaginal sling procedure (PVS) or male urethral
sling is performed in patients with stress-type or total-type
urinary incontinence. Only a small percentage of these
procedures are performed in males because these types
of incontinence are fare more prevalent in female patients.
Stress incontinence is when pressure is exerted on top
of the urinary bladder (i.e. from coughing, sneezing,
laughing, lifting, etc.) and the patient consequently
leaks urine. With normal anatomy, the tissue structures
that surround the urethra (the tube through which you
urinate) would tighten up in response to this increase
in pressure to prevent leakage. If the tissue is no longer
supportive, the urethra moves up and down (termed urethral
hypermobility)resulting in leakage. In total incontinence,
the walls of the urethra itself have lost coaptation (the
ability of the inner layers to close together) and a
patient constantly leaks throughout the day and/or night.
A PVS or male sling procedure may help correct either
of these problems by simultaneously pushing the walls
of the urethra together and/or by preventing the hypermobility(up
and down movement) associated with pressure on top of
the bladder. Some patients have both problems.

Currently, there are many varieties of sling material
available for the surgeon to use. Some are part of your
own tissue, some are processed tissue from a cadaver
(deceased person) donor, some may be processed tissue
from another animal species, and some are completely
artificial. The type used will depend on your prior surgeries
(if applicable) and anatomy, your surgeon's preference,
and input from you after you understand the pros and
cons of each type. In your surgical consultation, we
will have discussed the type to be used in your procedure.

Prior to your surgery, we may have already performed
a urodynamic test (UDT). This is a minor office procedure
used to specifically evaluate problems of urinary incontinence
or other problems with urination. Often, other possible
conditions causing incontinence need to be excluded prior
to recommending a PVS or male sling. Occasionally, the
diagnosis (based on your symptoms and physical examination)
is straightforward, and UDT is therefore unnecessary.

Preparation

As with any procedure in which anesthesia is administered,
you will be asked not to eat or drink anything after
midnight on the evening prior to your surgery. You may
brush your teeth in the morning but not swallow the water.
If you are on medications that must be taken, you will
have discussed with us and/or the anesthesiologist and
instructions will have been given to you.

The procedure will not be performed in you are currently
taking, or have recently taken any medication that may
interfere with your ability to clot your blood ("blood
thinners, aspirin, anti-inflammatory medicines, etc.").
The most common of these medications are aspirin and all
related pain relievers or anti-inflammatory compounds
(whether prescription or over-the-counter). Please refer
to the attached list and tell us if you took any of
these within the past 10 days. If your new medication
is not on the list, alert us immediately so that we may
ensure optimal procedure safety. We will have reviewed
all of your current medications with you during the pre-operative/pre-procedure
consultation.

You are obligated to inform us if anything has changed
(medication or otherwise) since your previous visit.

*It is probably to your advantage not to strain to
have a bowel movement in the week after the procedure.
We therefore recommend that for the entire week before
the procedure, you avoid constipating foods such as rice,
bananas, and red meat. You should be eating lots of fruits
and vegetables as well as oatmeal and cereals. If you
have a known problem of constipation, you should administer
an enema one hour before bed the night before your procedure.

Procedure

To review the basics of what we discussed in the
office: The procedure usually takes 1-2hours depending
on an individual's anatomy and whether a previous operation
has taken place in this same area. There are some techniques
that may only take 30 minutes. Not all patients are suitable
candidates for these techniques. A suprapubic tube (small
catheter placed through the lower abdomen and into the
bladder) may be inserted. This temporary tube would
be used in the immediate post-operative period to empty
your bladder and possibly measure residual urine volume
(the amount of urine left in the bladder after you urinate).
Many patients and certain techniques do not require placement
of this tube. In some patients, a tube is left in the urethra
only for a few days or longer. In some patients, no
tubes are left at all.

Female: Depending on your surgeon's
preference, the surgery may be done completely through
one or two incisions in the vagina; or through a combination
of a vaginal incision and a small lower abdominal incision.
The vaginal incision is made for placement of the sling material
around the bottom of the urethra. The very low abdominal
incision may be for placement of the tiny bone screws
into the pubic bone, to anchor the sutures in another fashion,
or to obtain some of your own body tissue to use as
the sling material. When the procedure is done only through
the vagina, the tiny screws may be placed into the underside
of the pubic bone instead of the upper margin of the
bone. If used, the screws are attached to a very strong
suture material that secures the sling in proper position.
During the procedure we may perform a cystoscopy (placing
a small telescope into the bladder to visualize the
inside) to ensure that everything is correctly positioned.
Cystoscopy is not always necessary. The incision sites
are then closed and your procedure is completed.

Male: For the most part, the procedure
is the same. The incision(s) that were vaginal in the female
are in the perineum (area between the scrotum and the
anal region) in the male. As in the female, the procedure
may be done solely through this incision, or can be
combined with a small incision on the suprapubic (very
low abdomen) area. Again, that will depend on the surgeon's
preference of where to position the bone anchors (if
used), or whether to use the patient's own tissue for
a sling material.

Post Procedure

You will be in the recovery room for a short time
before being sent to your hospital bed. Although often
an ambulatory procedure, some patients usually will
stay overnight in the hospital. There may be some discomfort
around the incision sites within the vagina (orperineum
in the male) and on the lower abdomen. Most patients
have some sense of urgency(the feeling of a need to
urinate). There will be a dressing over the abdominal
incision site which is to remain until your follow-up
visit unless otherwise directed.

Suprapubic Tube (SPT): If used, you may be discharged
home with a SPT. It will remain for a week or so
until you are urinating well and adequately emptying
your bladder. You will be instructed on how to easily
open and close the drainage switch. The tube may
serve two purposes:

You will attempt to urinate when you go
home. If you are unsuccessful, you can simply
open the tube and drain the urine from your
bladder. When you are completely empty(no more
draining from the tube), you will close the
switch and allow your bladder to fill again over
the next several hours (time will vary according
to how much fluid you are drinking). When you
get another sensation to urinate, you will go
to the bathroom and attempt to go. Again, if
you cannot, you will open the tube, empty the
bladder, close the tube, and try again later.

If you do urinate, you will open the tube
when you believe that you are done urinating. The
reason for doing so is to determine whether
you are emptying your bladder fully. If there is
urine remaining in the bladder, you will record
how may ounces were left. You will do this each
time you urinate so that you and your surgeon
know if you are effectively emptying you bladder
and thus ready to have the tube removed.

Urethral Catheter: Sometimes a catheter is left
in the urethra and removed a few days or week later
to see if you can urinate on your own. If you cannot,
it can be replaced, or you can learn self-catheterization.

Self-Catheterization: You may be instructed
on how to catheterize yourself. The indications to
do so may be the same. In other words, you would
do it if you cannot urinate yet. You may also be
asked to catheterize to measure what is left in
the bladder after urinating.

There may be small blood staining on the wound dressing.
If the dressing becomes soaked, or you see active blood
oozing, please contact us immediately. You may shower
two days after surgery, but no bathing or swimming (unless
otherwise instructed). Some surgeons may ask you to take
warm baths a couple of times a day a few days after
your surgery. We ask that you refrain from any strenuous
activity or heavy lifting until your follow-up office
visit.

Every patient has some degree off swelling and bruising,
and it is not possible to predict in whom this might
be minimal or significant. It is very important that
you intermittently apply ice to the abdominal area as
soon as you return home for 24 hours as instructed.

We strongly encourage you to take at least one week
off from work and perhaps more if your occupation requires
strenuous activity or heavy lifting. In the first 48
hours, it is to your advantage to minimize activity and
to often rest in a lying down position. Periodic walking
is encouraged. Some patients have almost no discomfort
while others are somewhat uncomfortable for a few days
to weeks. Severe pain is unlikely but possible.

We may provide you with a prescription for pain medication
to alleviate most of the discomfort. Take this medication
as prescribed and as needed. An antibiotic prescription
may also be given and should be taken until completion.
If any side effects occur, contact our office immediately.

*You must refrain from any strenuous activity or
heavy lifting until we tell you otherwise. Sexual activity
of any sort is absolutely prohibited (usually 4-6 weeks)
until we tell you that you may resume.

Expectations of Outcome

Sling placement is a very effective modality for
curing stress or total urinary incontinence."Normal
voiding" may be delayed for many weeks due to swelling
and operative manipulations. Improvement is usually gradual
and not immediate. *There is an entity termed "bladder
instability" that should be understood. It is actually
not a complication of the surgery because we expect some
degree of its presentation in anywhere from 30-40% of
patients following repair of urethral hypermobility.
Because the bladder neck support has been restored, you
may develop urinary frequency and/or urgency (a sensation
to urinate urgently). When severe, this rarely can be
associated with urge-type incontinence (strong urge
to void with an uncontrolled loss of some urine). The
symptoms are usually mild and resolve with time. In few
patients, medications could be necessary to relax the
bladder. Very rarely are other treatments necessary.

Possible Complications of the Procedure

ALL surgical procedures, regardless of complexity
or time, can be associated with unforeseen problems.
They may be immediate or even quite delayed in presentation.
While we have discussed these and possibly others in
your consultation, we would like you to have a list
so that you may ask questions if you are still concerned.
Aside from anesthesia complications, it is important
that every patient be made aware of all possible outcomes
which may include, but are not limited to:

Urinary Tract Infection or Sepsis: Although
we may give you antibiotics prior to and after the
operation, it is possible for you to get an infection.
The most common type is a simple bladder infection
(after the catheter is removed) that presents with
symptoms of burning urination, urinary frequency
and a strong urge to urinate. This will usually resolve
with a few days of antibiotics. If the infection
enters the bloodstream, you might feel very ill.
This type of infection can present with both urinary
symptoms and any combination of the following: fevers,
shaking chills, weakness or dizziness, nausea and
vomiting. You may require a short hospitalization
for intravenous antibiotics, fluids, and observation.
This problem is more common in diabetics, patients
on long-term steroids, or patients with disorders
of the immune system.

Wound Infection: The incision sites can become
infected. While it typically resolves with antibiotics
and local wound care, occasionally, part of all
of the incision may be open and require revision
and/or catheter replacement. *If you have symptoms
suggesting any of the above after your discharge
from the hospital, you must contact us immediately
or go to the nearest emergency room.

Treatment Failure: Although usually associated
with a high success rate, the procedure can fail
immediately, or months to years later. In this regard,
stress-type or total incontinence may persist or
resume.

Urinary Retention: Retention is the inability
to urinate and occurs in fewer than 5%of cases.
Usually, a patient is able to urinate normally within
2-3 weeks following the procedure. However, if retention
is prolonged, a catheter may be necessary. If you
had a SPT placed, it may remain in for a while longer.
Otherwise, you could learn to self-catheterize or
simply have a urethral catheter placed back in for
a few days at a time. It would periodically be removed
to test whether you are able to urinate. We always
encourage patients to be patient, because urinary
retention usually resolves with time and observation.
In rare instances of prolonged retention, a corrective
procedure may be required. Factors which may delay
the rapid return of voiding include: excessive sling
tension, poor bladder function before the surgery,
and multiple repaired organs (i.e. a dropped bladder,
a dropped uterus, or a prolapsed rectum) during
the same surgery. Urodynamic testing may need to
be performed for further assessment.

Blood Loss/Transfusion: The vaginal region is
quite vascular. Usually blood loss in this procedure
is minimal to moderate. In 1-2% of cases, blood
loss can be significant enough to necessitate transfusion.

Deep Vein Thrombosis (DVT)/Pulmonary Embolus
(PE): In any operation (especially longer operations),
you can develop a clot in a vein of your leg (DVT).
Typically, this presents 2-7 days (or longer) after
the procedure as pain, swelling, and tenderness
to touch in the lower leg (calf). Your ankle and
foot can become swollen. If you notice these signs,
you should go directly to an emergency room and
also call our office. Although less likely, this
blood clot can move through the veins and block
off part of the lung (PE). This would present as
shortness of breath and possibly chest pain. We may
sometimes ask the medical doctors to be involved
with the management of either of these problems.

Sling Erosion: It is possible for the sling
material to erode through the tissue that surrounds
it. In the female, if the vaginal tissue breaks
down, the sling can often be removed with a minimal
procedure. Often, the patient is still continent
because scar tissue from the surgery will continue
to support the urethra. On the contrary, if the
back of the sling erodes into the urethra in either
females or males, the surgical removal is more involved,
and the rates of incontinence afterward are higher.

Bleeding/Hematoma: When a small blood vessel
continues to ooze or bleed after the procedure is
over, the area of collected blood is referred to
as a hematoma. The body normally re-absorbs this
collection over a short period of time, and surgical
drainage is rarely necessary.

Lower Extremity Weakness/Numbness: This, too,
is a rare event which may arise due to your position
on the operating table. It is possible in procedures
in which you are in the lithotomy (legs up in the
air) for a long period. The problem is usually self-limited with
a return to baseline expected.

Injury from Suprapubic Tube: If a suprapubic
tube is being placed, it can rarely puncture a structure
adjacent to the bladder. Although rare in any instance,
the small intestine is the most commonly involved
organ. When recognized, a general surgeon may be
consulted to repair the intestine or other organ.

Chronic Pain: As with any procedure, a patient
can develop chronic pain in an area that has undergone
surgery. Typically, the pain disappears over time,
although some feeling of numbness may persist. If
persistent, further evaluation may be necessary.

Transferred Viral Infection: With the use of
human cadaveric material, transferred virus is theoretically
possible. The processing of this material is quite
extensive. With use in tens of thousands of patients,
we are not aware of a single published case of transferred
viral infection.

We provide this literature for patients and family
members. It is intended to be an educational supplement
that highlights some of the important points of what
we have previously discussed in the office. Alternative
treatments, the purpose of the procedure/surgery, and
the points in this handout have been covered in our face-to-face
consultation(s).

The information contained in this document is intended
solely to inform and educate and should not be used
as a substitute for medical evaluation, advice, diagnosis
or treatment by a physician or other healthcare professional. While
Delta Medix endeavors to ensure the reliability of information,
such information is subject to change as new health information
becomes available. Delta Medix cannot and does not guaranty
the accuracy or completeness of the information contained
in this document, and assumes no liability for its content
or for any errors or omissions. Please call your doctor
if you have any questions.